Provider Demographics
NPI:1043076060
Name:PATEL, MIRA
Entity type:Individual
Prefix:
First Name:MIRA
Middle Name:
Last Name:PATEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 CHILTON WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRLESS HILLS
Mailing Address - State:PA
Mailing Address - Zip Code:19030-3306
Mailing Address - Country:US
Mailing Address - Phone:610-400-4344
Mailing Address - Fax:
Practice Address - Street 1:202 CHILTON WAY
Practice Address - Street 2:
Practice Address - City:FAIRLESS HILLS
Practice Address - State:PA
Practice Address - Zip Code:19030-3306
Practice Address - Country:US
Practice Address - Phone:610-400-4344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
PAPC016823101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)